Summary The pilot and sole occupant of the DHC-2 seaplane, registrationC-GJST, serial number1368, was on his first flight of the season on the Ottawa River at Gatineau, Quebec. This training flight, conducted according to visual flight rules, was to consist of about 12touch-and-go landings. The aircraft took off at approximately 1300 eastern daylight time, and made several upwind touch-and-go landings in a westerly direction. At approximately 1340 eastern daylight time, the aircraft was seen about 50feet above the surface of the water proceeding downwind in an easterly direction, in a nose-down attitude of over 20degrees. The right float then struck the water and the aircraft tumbled several times, breaking up on impact. Despite the waves and gusting wind on the river, some riverside residents who witnessed the accident attempted a rescue, but the aircraft sank before they could reach it. Even though the pilot was wearing a seat-belt, he sustained head injuries at impact and drowned. Ce rapport est galement disponible en franais. Other Factual Information The pilot held a valid commercial pilot licence with a seaplane endorsement and instrument rating. The last entry in his pilot logbook indicates that, as of 10October2003, he had accumulated 1709flying hours, including 1300hours on seaplanes, more than 700hours of those on two DHC-2 Beavers of which he was co-owner. He was considered by his peers to be a careful and conscientious pilot. Every year in early summer, since he had not flown a seaplane for several months, he made a solo training flight to perfect his skills. This flight consisted normally of about 12touch-and-go landings. Based on the autopsy and toxicology testing, there was no evidence to indicate that the pilot's performance was degraded by physiological factors. The regulations state that, to fly an aircraft as pilot-in-command, a pilot must have flown as pilot-in-command or co-pilot during the previous five years and passed a periodic training program within the previous 24months. This pilot had made his last flight seven months previously and had renewed his instrument rating 19months previously. The Gatineau Airport Flight Service Station, located eight nautical miles west of the accident site, recorded the following weather conditions at 1800 Coordinated Universal Time (UTC), a few minutes after the accident: a few scattered clouds at 4500feet and 25 000 feet above ground level (agl), visibility 15statute miles, temperature 27C, dew point 15C, and winds from the west at 11knots with gusts to 17knots. On windy days like the day of this occurrence, the pilot sometimes used an adjoining bay to land. That way, he was more sheltered from the wind and waves. The last flight entered in the aircraft journey log was on 12November2003, seven months earlier, when a pilot from the approved maintenance organization made a ferry flight after the annual inspection. The aircraft was then stored outside over the winter. In early June, the pilot tested the engine for 45minutes to ensure that it was working properly. In the ensuing days, the aircraft was placed on the water, then on a dry dock, which kept the aircraft out of the water. A few days before the occurrence flight, the aircraft was refuelled by the pilot from his private supply. Inspection of the refuelling system on the ground and a fuel sample taken from the system revealed no problems with the quality of the fuel. Examination of the aircraft's fuel system revealed that there was fuel on board at the time of the accident. On the morning of the accident, the pilot appeared to be well rested. He went to the shop where he worked to assign tasks to his employees, then he planned some family activities for late that day. In the late morning, as he had been doing regularly for several years, he went to his chiropractor's for a treatment session before coming back for his flight, which he was looking forward to. The pilot did a pre-flight inspection before starting the engine and taking off in a westerly direction. He made some upwind touch-and-go landings in a westerly direction, as he was accustomed to doing. The aircraft was then observed about 50feet above the river, two miles east of the place where the first landings were made (seeFigure1), with a tail wind and a nose-down attitude of over 20degrees. A few feet above the surface, the aircraft banked slightly right and its nose-down attitude increased slightly. The impact with the surface of the river destroyed the aircraft, which sank within a few minutes. The pilot was not in radio contact with air traffic services and no distress calls were received. The aircraft was equipped with a fixed, automatic emergency locator transmitter (ELT), but no distress signals were reported. Examination of the ELT in the TSB Engineering Laboratory indicated that it was probably emitting a distress signal after the impact, but once it was submerged, the water would have considerably reduced the range of the signal and it would not have been picked up. Shortly afterward, water entering the housing would have quickly caused a short circuit, neutralizing the ELT. Unless it is picked up by an aircraft flying over the accident area, a distress signal can take up to 90 minutes before being received by the SARSAT and COSPAS satellites currently in orbit. Examination of the propeller and engine revealed that the engine was producing power at the time of impact. It was established that the weight of the aircraft was less than the maximum allowable weight and that the centre of gravity was within the prescribed limits. Despite underwater visibility of less than two feet when the search for the wreckage was conducted, all flight control surfaces were found at the site, except the left elevator. Examination of the left elevator attachment flange indicated damages attributable to the impact. Examination of the fittings of the left wing strut, which was also missing, also indicated damages attributable to the impact. The flaps were in the retracted position at the time of impact; this was unlike the usual practice of this pilot, who always landed with flaps extended. Examination of the aircraft technical logs indicated that the aircraft was maintained in accordance with Canadian Aviation Regulations (CARs) Rule625, AppendicesB andC. Accordingly, the aircraft was required to be inspected annually at intervals not exceeding 12months. The last inspection of the aircraft was done on 04November2003 by the approved maintenance organization that had been maintaining the aircraft for several years. In previous years, airworthiness directives were completed at the same time as the annual inspections and a follow-up of airworthiness directives was entered in the aircraft technical logs. Despite that follow-up, only 4 of the 10 airworthiness directives required at the time of the last inspection were completed and entered correctly as required by the CARs. The following six airworthiness directives were not entered as completed in the technical logs: CF-98-38 - Bulkhead cracks at station 228 - To control cracking at station228 and to prevent a loss of strength CF-97-06 - Elevator tip ribs - To reduce the risk of flight control difficulties CF-91-42 - Tailplane spar cracks - To prevent failure of the tailplane CF-84-01R1 - Horizontal torque tube - To detect cracking and prevent failure of the horizontal torque tube CF-80-25 - Elevator root rib - To detect elevator root rib cracks CF-85-08R3 - Wing strut lower fitting - To prevent failure of the wing lift strut It appears that the approved maintenance organization had completed five of those six airworthiness directives, but had not entered them in the technical logs. As for the sixth airworthiness directive (CF-85-08R3), that inspection had not been done. The aircraft held a valid certificate of airworthiness, but it was not in effect at the time of the accident because of the six airworthiness directives that had not been entered in the technical logs. The owners of the aircraft were not aware that they were responsible for ensuring that the applicable airworthiness directives were completed. They thought that the approved maintenance organization would ensure that the aircraft was airworthy on each inspection.